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Implementing the family-MUAC approach for infants under 6 months in the context of COVID-19 in Ethiopia

Early online article pending completed editorial review.

By Ritu Rana, Hatty Barthorp, Mary T Murphy and Alemayhu Beri

Ritu Rana is a GOAL Nutrition Research Advisor (Management of At-risk Mothers and Infants under six months, MAMI). She has a PhD in nutrition (India) and a second Master’s in Nutrition for Global Health (UK). Ritu has been working on nutrition research for eight years and is also affiliated with the Indian Institute of Public Health Gandhinagar (IIPHG).

Hatty Barthorp is a GOAL Global Nutrition Advisor. She has worked on emergency, transitional and development programmes for 18 years.

Mary T Murphy is a Refugee Programme Manager at GOAL Ethiopia. She has over 20 years’ experience in nutrition and humanitarian programming.

Alemayhu Beri is a supervisor for Management of At-risk Mothers and Infants under 6 months (MAMI) and Senior Community Management of Acute Malnutrition (CMAM) Programme Officer at GOAL Ethiopia. He has around nine years’ experience in humanitarian programming. 

The authors would like to thank the DropBox Foundation and Nächstenliebe Weltweit for funding this work in collaboration with the Bureau of Population, Refugee, and Migration (BPRM); the United States Department of State; the European Commission Humanitarian Office (ECHO); the United Nations High Commission for Refugees (UNHCR); the Agency for Refugees and Returnees Affairs (ARRA) and the United Nations Children’s Fund (UNICEF).  

 

Location: Ethiopia

What we know: The COVID-19 pandemic has hastened the scale-up of home screening of malnutrition through the measurement of mid-upper arm circumference (MUAC) by family members.

What this article adds: In response to the COVID-19 pandemic, GOAL made two types of adaptations to its community Management of At-risk Mothers and Infants under 6 months (MAMI) programme in Gambela, Ethiopia: i) the family MUAC approach was introduced to enable home-based screening of infants under six months, and ii) a new type of reversible MUAC tape was introduced to allow for the specifics of screening children less than 6 months of age. Measurement accuracy analysis showed that the vast majority of caregivers trained by Community Outreach Agents (COAs) correctly identified the MUAC of their infants. The proportion of infants referred by families (self-referrals) increased from 9% (May) to 30% during 2 months post training follow up (June-July). Outreach referrals conversely reduced from 78% to 65%. Before training, 77% of enrolments were attributed to outreach and self-referral combined, which rose to 92% after training, demonstrating a greater total percentage of admissions coming from community-focused active case finding over facility based and mass screening activities. Based on those promising results, GOAL will strengthen the scale-up of family-MUAC approach to further reduce the points of physical contact between health workers and beneficiaries and will continue to work on challenges to implementation.

Background

The measurement of mid-upper arm circumference (MUAC) by community health workers and caregivers is a promising approach for community-based case identification (Bliss et al,  2018; Blackwell et al, 2015). Although ‘MUAC by community health workers and caregivers’ approach has proven simple, evidence suggests it does require adequate operational support, training, and supervision (Bliss et al, 2018). While the approach has been tested and increasingly used in children between 6-59 months, there are currently no agreed international references for MUAC, although there is growing evidence of its effectiveness in identifying infants under 6 months at increased risk of mortality in several African countries (Mwangome et al, 2012; Lelijveld et al, 2017).  

The 2020 WHO and UNICEF implementation guidance for early detection of malnutrition in children aged 0-59 months in the context of COVID-19 recommends the use of MUAC as a ‘reduced physical contact’ approach (UNICEF, 2020) that includes building capacity of caregivers in measuring MUAC.  In addition to children between 6-59 months, recommended adaptations also include use of MUAC to identify nutritionally at-risk infants under 6 months using the following thresholds: <11.0 cm for 0-6 weeks and <11.5 cm for 7 weeks-6 months (UNICEF, 2020).1

To respond to the COVID-19 emergency, GOAL introduced various adaptations to its nutrition programmes, including in its community Management of At-risk Mothers and Infants under 6 months (MAMI) programme. Since 2014, GOAL has been implementing MAMI in four refugee camp sites in Gambella, Ethiopia - Kule-1, Kule-2, Tierkidi-1 and Tierkidi-2 (Burrell et al, 2020). For screening of infants under 6 months, Community health workers – locally called Community Outreach Agents (COAs) – have been using MUAC tapes designed for use with older children (6-59 months) since 2016.

Following WHO’s declaration of COVID-19 as a pandemic (March 2020), GOAL began to implement community-based case identification using specially designed MUAC tapes called MAMI-MUAC (Figures 1a and 1b). These specially designed tapes were developed by GOAL in 2019. They are reversible (one side is used for infants under 6 months and the other is used for older children and pregnant and lactating women) and they have two colour-coded versions (enumerated and non-enumerated).

Two types of adaptations were implemented: i) the family2 MUAC approach was introduced to enable home-based screening of infants in the community, in addition to existing screening by COAs and ii) the new type of reversible MAMI-MUAC tape was introduced for both COAs and caregivers (Rana et al, 2020).

Figure 1a: Enumerated, colour-coded reversible MAMI-MUAC tape, for community health workers

Top: infants <6 months
Bottom: children 6-59 months and pregnant and lactating women

Figure 1b: Non-enumerated reversible MAMI-MUAC tape, for caregivers

Top: infants <6 months
Bottom: children 6-59 months and pregnant and lactating women

Aim and objectives

The aim was to document the use of the newly designed MAMI-MUAC tape by COAs and caregivers, and to assess effectiveness. To fulfil this aim, the following objectives were set:

  1. To provide training to COAs on training caregivers on assessing the nutritional status of their infants using the MAMI-MUAC tape. 
  2. To record coverage of COAs and caregivers trained, performance of COAs and caregivers in undertaking MAMI-MUAC measurements, and implications on case enrolment in MAMI programme following this training.
  3. To conduct a 2 months post-training follow-up assessment on a sample population to assess whether the COAs and caregivers continue to identify and refer infants under 6 months correctly.
  4. To record experience of using the MAMI-MUAC tapes.

Methods

Training of COAs and caregivers

We conducted the training in 2 phases – one for the COAs in March 2020 and another for the caregivers of infants under 6 months in May 2020. All four locations – Kule-1, Kule-2, Tierkidi-1, and Tierkidi-2 – were covered (Table 1). The MAMI supervisor trained the COAs (using enumerated tapes, Figure 1a), with each training group consisting of 30 participants or less. Thereafter the trained COAs then started using the tapes in the community. Two months later (May 2020), the COAs then trained caregivers (using non-enumerated tapes, Figure 1b). These cascaded trainings consisted of a series of short, house-to-house training sessions that respected infection prevention control (IPC) measures.

We collected data on MAMI-MUAC measurements by ‘MAMI supervisors’, ‘COAs’, and ‘caregivers’ during both COA and caregiver trainings. The analysis included two comparisons in measurements – one between ‘MAMI supervisor and COAs’ and another between ‘COAs and caregivers’. We present the results as measurement accuracy among COAs and caregivers.

Table 1: Number of COAs and caregivers trained, overall and by camp

The 2 months post-training follow-up assessment was carried out in July 2020 on a sample population in two phases – one with ‘MAMI supervisor and COAs’ and another with ‘COAs and caregivers’, while respecting IPC measures. Table 2 presents the size of the sample, i.e. the number of COAs and caregivers from the four camps that were included in the follow-up assessment. We had planned to follow up all COAs and around a third of the caregivers, but several COAs were absent on the day of assessment. Similar to the initial training, during follow-up assessment we collected data on MAMI-MUAC measurements by ‘MAMI supervisor’, ‘COAs’, and ‘caregivers’. Since for the follow-up assessment we selected a sample population, we were able to collect more detailed information on the following case identifications – true positive, true negative, false positive and false negative – to calculate sensitivity and specificity (Box 1). Additionally, using a simple checklist (yes/no/multiple choice), we also collected information on caregivers’ experience of using the MAMI-MUAC tape including on wear and tear, place of storage, confusion over using the tape, frequency of assessment, and any barriers to referral.  

Table 2: Sample size of COAs and caregivers from respective camps for 2 months post-training follow-up assessment

Box 1: Validity of screening using MAMI-MUAC tapes during post-training follow-up assessment

a = infants who are at-risk of malnutrition and were identified in red category by the MAMI-MUAC tapes (true positive)  

b = infants who are not at-risk of malnutrition but were identified in red category by the MAMI-MUAC tapes (false positive)  

c = infants who are at-risk of malnutrition but were identified in green category by the MAMI-MUAC tapes (false negative)  

d = infants who are not at-risk of malnutrition and were identified in green category by the MAMI-MUAC tapes (true negative)  

Sensitivity = a/a + c and Specificity = d/b + d

Assessing identification of malnutrition and referrals to MAMI

In order to ascertain whether there had been a change in the origin and proportions of case referrals, we analysed case referrals following training. We extracted enrolment data from the MAMI programme database3 where MAMI referrals were recorded as follows: self-referral (referral by caregivers), outreach referral (referral by COAs), heath facility referral, inpatient referral, and monthly screening referral. We compared an average of case referrals for 12 months pre-training, to an average of case referrals during the month of training and then during the 2 months post training to show trends in referral type. We also compared average enrolments by community-based referrals, in the year before training (May 2019 to April 2020) and after training (May to July 2020).     

Findings

Coverage, performance of COAs and caregivers in undertaking measurements

We trained 112 COAs (89.7%) and 1,289 caregivers (100%) with infants under 6 months (Table 1). During the 2 months follow-up assessment, we reviewed 93 COAs (74.5%) and 555 caregivers (44.5%) (Table 2). Measurement analysis at the point of training showed 90.0% of COAs and 78.5% caregivers correctly identified at-risk infants. During post-training follow-up, accuracy among COAs and caregivers increased to 97.5% and 99.5%, respectively. Furthermore, the detailed analysis during the follow-up assessment showed a sensitivity rate of 100% among both COAs and caregivers and a specificity of 94.7% among COAs and 98.6% among caregivers (Table 3). 

Table 3: Sensitivity and specificity of measurements by COAs and caregivers during 2 months post-training follow-up assessment 

Implication on case enrolment as represented by referral type        

Pre-training, outreach referrals contributed to 77% of MAMI enrolments and there were no self-referrals (Figure 2). Following the training, we identified a progressive increase in cases referred by families (self-referrals), from 9% (May) to 30% during 2 months post training follow up (June-July). Outreach referrals conversely reduced from 78% to 65% (Figure 2). Comparing average enrolments by community-based referrals, in the year before training and after training, we observed that 77% of enrolments were attributed to outreach and self-referral combined before training, which rose to 92% after training, demonstrating a greater total percentage of admissions coming from community-focused active case finding over facility based and mass screening activities (Figure 3).

Figure 2: Comparing average enrolments in MAMI programme 12 months pre-training, during the month of training and 2 months post-training

Figure 3: Comparing average community-based referrals (outreach and self-referral combined) in MAMI programme in the year before training and after training

Experience of using MAMI-MUAC tapes

During follow-up assessments we asked families about their experiences of using the MAMI-MUAC tapes. Findings showed that 56% of families reported no wear and tear at all, 67% reported no confusion while using the tapes and 93% reported no barriers to referring their infants. Of caregivers that experienced wear and tear, it transpired this was minimal, and was mainly reported as folding of the tape from the corners and in the middle due to its place of storage. Functionality of the tape was not affected. Of caregivers that reported confusion while using the tapes, the majority reported the confusion was related to the reversible nature of the tapes. Regarding the storage of tapes, the majority (65%) said they stored tapes in a bag. A few (9%) said they kept it on the table, 6% kept it on the wall, 4% on the front of the door, 4% in a book while 2% reported they had lost their MUAC tapes. Regarding use of tapes the majority said they used it weekly (69%), while others said they used it every 15 days (12%), daily (12%), and monthly (7%).

Discussion

We achieved a high coverage of training (>90%) with both COAs and caregivers of infants under 6 months. Measurement accuracy analysis showed that the vast majority of caregivers trained by COAs correctly identified the MUAC of their infants. The 2-month follow-up assessment showed that the proportion of COAs and caregivers who correctly identified the status of infants using the MAMI-MUAC approach was even greater than that of the initial training assessment. We assume this may be attributable to greater familiarisation with the tape over time, hence the ability to record accurate measurements improved.

Our findings also show that a substantial proportion of families are actively screening and self-referring their infants, despite the community also benefiting from widespread, continual, active case finding in the community by COAs. This implies families are engaged and motivated to play an active role in their infant’s wellbeing through early case identification and referral.

Screening using MAMI-MUAC tapes by COAs and caregivers appears to be a feasible approach, accounting for 92% of the total enrolments between May and July 2020 (Figure 3). This means in the absence of such a training, and without the use of the MAMI-MUAC tool, it is plausible that many of these ‘at risk’ cases who need support would be missed. This highlights the value of MUAC screening in the context of COVID-19.

Although we did not attempt to statistically validate our findings, our data could be useful to other organisations who are interested in implementing a similar approach. Our findings demonstrate that the MAMI-MUAC can function well when appropriate training and supervision are provided.  

Next steps

Through the next post-training assessment (6 months follow up planned for November 2020), we will further investigate the durability of the tapes. We will also assess how we can better address confusion in tape utility and identify where barriers are arising in referral mechanisms. We will then investigate how to address these challenges. The results of this analysis will be incorporated in the refresher training planned in January 2021.

After nine months of implementation, we plan to discuss with partners about the feasibility to shift the community-based screening from ‘screening by COAs and families’ to ‘screening by families-only’. This would reduce the points of physical contact between health workers and beneficiaries and thus the risk of COVID-19 transmission. Additionally, the time saved by health workers could be utilised to provide other services such as community-based nutrition education or counselling, absentee and defaulter tracing, and recording programme data.    

For more information please contact Hatty Barthorp.

 

More information can also be found at:

GOAL (2020). MAMI mid-upper arm circumference (MUAC) tapes.
www.ennonline.net/mamimuactapes

GTAM Conversations on how programmes are adapting in light of COVID-19: Implementing the Family MUAC approach in Gambella, Ethiopia. https://www.ennonline.net//mediahub/podcast/gtamconversationsmuacethiopia


Endnotes

1 There are currently no globally established MUAC thresholds for infants under 6 months. These thresholds are based on research in several African countries.

2 The term family includes mothers and/or caregivers

3 MAMI programme database was maintained since May 2019


References

Blackwell, N., Myatt, M., Allafort-Duverger, T., Balogoun, A., Ibrahim, A., & Briend, A. (2015). Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Archives of public health = Archives belges de sante publique, 73(1), 26. https://doi.org/10.1186/s13690-015-0074-z

Bliss, J., Lelijveld, N., Briend, A., Kerac, M., Manary, M., McGrath, M., Weise Prinzo, Z., Shepherd, S., Marie Zagre, N., Woodhead, S., Guerrero, S., & Mayberry, A. (2018). Use of Mid-Upper Arm Circumference by Novel Community Platforms to Detect, Diagnose, and Treat Severe Acute Malnutrition in Children: A Systematic Review. Global health, science and practice, 6(3), 552–564. https://doi.org/10.9745/GHSP-D-18-00105

Burrell A, Barthorp H. (2020). GOAL’s experiences of management of at-risk mothers and infants (MAMI) programming in Ethiopia. Field Exchange 62.

Lelijveld N, Kerac M, McGrath M, Mwangome M and Berkley J A. (2017). A review of methods to detect cases of severely malnourished infants less than 6 months for their admission into therapeutic care. ENN, The Child Acute Illness and Nutrition Network and LSHTM.

Mwangome, M. K., Fegan, G., Mbunya, R., Prentice, A. M., & Berkley, J. A. (2012). Reliability and accuracy of anthropometry performed by community health workers among infants under 6 months in rural Kenya. Tropical medicine & international health : TM & IH, 17(5), 622–629. https://doi.org/10.1111/j.1365-3156.2012.02959.x

Rana R, Barthorp H, Murphy MT. (2020). Leaving no one behind: Community Management of At-risk Mothers and Infants under six months (MAMI) in the context of COVID-19 in Gambella refugee camps, Ethiopia. World Nutrition 11(2):108-20.

United Nations Children’s Fund and World Health Organization. (2020). Prevention, Early Detection and Treatment of Wasting in Children 0-59 Months through National Health Systems in the Context of COVID-19. UNICEF: New York.

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Ritu Rana, Hatty Barthorp, Mary T Murphy and Alemayhu Beri (2020). Implementing the family-MUAC approach for infants under 6 months in the context of COVID-19 in Ethiopia. , January 0001. www.ennonline.net/fex/ethiopiagoalcovidadaptations

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